Capitalist Corner

May 20, 2005

Hellllllooooo Nurse!

The New York Times has a cute op-ed arguing that America should replace the unknown Surgeon General with a National Nurse whose pronouncements would focus on prevention and healthy living. Sounds good, though we can still keep the surgeon general around for kicks and non-preventive giggles. In any case, this country really has to start paying more attention to nurses. Not only are we losing them at an alarming rate but any efforts to fix our health care system and lower costs are going to need nurses and their cousins, nurse practitioners, to act as the new system's backbone.

America's doctors simply make too much money. Sorry guys, you do. But I don't blame you for wanting the big bucks, the hell we put you through in order to net that MD is just absurd. Why, exactly, do pediatricians need to know advanced physics? Or wait, riddle me this: multi-variable calculus? We've essentially weeded out anyone who doesn't like science from attending med school, as the pre-med requirements are so killer. And all that says nothing of the ass-kicking that actually is med school, or the hazing that is residency. And -- best of all -- we make them pay handsomely, and take on lots of debt, for the privilege. Thanks AMA, for screwing everything up.

Unfortunately, the AMA is a powerful, powerful group and they're not going to be crossed. Doctors are not going to lose their royal paychecks and the credentialing process is not going to become saner. Which is why the AMA should be sidestepped, and we should simply pump money into the popularization, education, and deployment of nurse practitioners for general medical tasks. It's all that makes sense. (It's also, by the way, the sort of solution that would emerge if health care wasn't wholly controlled by gatekeeper docs. I'm no fan of HSA's, but we really need to push some of their competitive aspects out into the wider health care economy, we just need to do it through smarter means.)

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Make Medical schools more common and easier to charter. Allow other disciplines to be licensed physicians as we have with Osteopaths. Flood the market. Supply and demand.

Posted by: Robert Zimmerman | May 20, 2005 3:28:51 PM

Don't forget that the MD world protects their monopoly by limiting the number of Med School enrollments to keep supply lower than demand.

And, who can blame nurses when they are treated by MDs like dirt. The only thing worse than being under the supervision of an arrogant MD is to be supervised by a corporate lawyer, and the vast majority of both are really arrogant. I'd take cruel and unusual punishment than accept either of those alternatives.

The only thing sicker than our medical 'system' are the millions of people who get no care at all.

Posted by: JimPortlandOR | May 20, 2005 3:48:13 PM

best title ever.

Posted by: praktike | May 20, 2005 4:05:05 PM

Or better yet - take out the profit incentive . . . and I'm not talking about the doctors.

Physicians are skilled professionals - the deserve a good wage. And like yous siad, we torture them fro somewhere between 7 and 12 years before we really turn 'em loose. Not that they deserve the huge amount that some physicians make, but I'm fairly convinced that the multimillionaire doctors are unusual exceptions.

Just as malpractice insurance isn't a real cause of high healthcare costs, physician compensation isn't either. The main pain in the healthcare equation comes from the middle men - the major healthcare conglomerates, the insurers, and even the medical equipment manufacturers. They've created, instead of the so-called healthy competition we're always hearing the open market provides, unhealthy competition. As hospitals compete with each other for patients, with "newfangled machines" and better facilities, their cost of providing basic services to their patients grows. The pressure from to compete comes from both directions - the machinery manufacturers and sales industry reminds small hospitals that they can't compete without their new toys, and the big conglomerate that's taken them over reminds them that they need to compete in order to profit.

And who ends up paying? We do. Usually indirectly - through our insurers, who're also out to make a profit - and thus are essentially skimming off the top.

We need to pull two of those three factors out of the mix in order to change the way we provide healthcare. Out with the for profit healthcare conglomerates, and out with the for profit insurers. Neither can possibly make the best decisions for their patients when their first responsibility is to their shareholders.

Yeah yeah yeah, its the same old liberal socialized medicine argument, but it's still a good one.

The thing is, nurses salaries are already fairly high. The median base salary for an NP is $42K, an RN is $46K, a nurse with a masters earns $61K, with a doctorate $63.5K, anesthetists earn $93K (!). By comparison, an ER physician makes between $100K (in Baltimore) and $170K (in New York City). So, if we put upward pressure on nurses' wages and downward pressure on doctor's wages, pretty soon they are getting paid almost the same amount. Now, maybe that reflects the judgement that there is greater demand for nurses' services, which is, let's be frank, less savory than the work of doctors. But it's going to be a very hard sell.

Now, I think the real answer is to put downward pressure on the wages by, as you suggest, creating more doctors, particularly more GPs, and somehow steering us away from having so many doctors become specialists (reducing the cost of med school would also do the trick). But I think a side effect of that idea would be a slight drop in nurses salaries, though by the standards of hourly-wage jobs they would still be doing very well.

Ahh... as a graduate student in chemistry (finishing my doctorate SOON), I have to disagree with Ezra on the science thing. Not that we need doctors to know the minutae of quantum mechanics, but the lack of BASIC science and math skills of undergraduates is appalling. I was tutoring a student and going over a problem set. With a fairly straightforward derivation problem, it turned out that she was ignorant of logarithms ---something she should have learned in 2nd year high school! Believe me, science ignorance carries over into other topics...

Posted by: MikeyC | May 20, 2005 4:57:44 PM

Y'know, I agree with everything you said about just how bad many doctors treat nurses, and how they are picking up more responsibilities. NPs, to the best of my knowledge, don't get paid as well as doctors, but my MD has two working for him, and I pay the same for a doctor's visit whether I see the doc or one of the NPs. I'd like them to see the same payscale, if they're going to do the same job. And I'm dating a med student, which is giving me all kinds of insights into medical school that I don't really want to know. AND they've passed a law in Texas that is supposed to limit residents and fellows to an 80-hour work week, but my doctor friend tells me that 80 hours isn't enough time to get all his work done, so he signs off on "80 hours" and does what he needs to do. The system is overloaded, underfunded, and finds less support from the public, now that doctors are being painted with the same general brush as the dreaded HMO. We really need a rebuild of the entire system.

But I have to disagree with the objection to the pre-med prereqs. I'm a chemist, so I'm biased, but
I WANT my MD to have a science background. I want to know that they've had some training in assimilating and synthesizing technical information, and that they don't just memorize the info. Yeah, it's a LOT of information to memorize, but "Illness A = Cure B" should not be the whole of the Art of medicine. I would hope that the pre-med requirements don't dissuade someone from being a doctor, because that's the least of their worries. The course requirements for the pre-med work came out to about 30 hours at my old school, which is a bit more than a minor at most schools (isn't a minor 24 credits or thereabouts?). I don't think that's too much to ask from someone who will be poking and prodding me.

Maybe courses more tailored to the pre-med needs would be better. Does a doctor need to memorize the Light and Dark Cycles for photosynthesis? A course on Human Cell Biology might give the basics and more relevant focus for the pre-med student, as an example. And Vector Calc or Modern Physics is probably too much to ask.

But some real, hardcore science should be kept as an admissions requisite.

CS

Posted by: Captain Sunshine | May 20, 2005 4:57:57 PM

The premed requirements at my school came out as MORE than my actual major.

I agree that basic science is a must, but I fail to see where multivariable calculus and electrostatics fit if you want to be a GP.

Posted by: Kate | May 20, 2005 5:13:54 PM

My point isn't that science is useless -- indeed, researchers and certain sorts of specialists need enormously intense training. But, and I'm not arguing this is a good thing, the guy or gal who looks over your 4 year old with the flu doesn't need to calculate all that mane integrals...

Old joke: Your standard introductory physics class, filled with obnoxious-to-most-other-students pre-meds. The professor is in the middle of a long lecture on Newtonian motion, when one student snaps, and shouts "What is the point of learning this?"

The lecturer turns around, simply says "It saves lives," and goes back to the derivation.

After a few minutes, the same student shouts out "How will this help save lives?"

"It keeps ignoramuses like you out of medical school."

That being said, there are some instances where I can see knowledge of multivariable calculus useful to a pediatrician. Just because it won't be an everyday occurrence doersn't mean it's not something they should know.

(The residence hazing, however, should stop. 30 hours on one's feet doesn't teach you anything, and is a danger to the people you're supposed to be treating.)

I think there are three issues. One, the AMA is dedicated, like any professional org/union, to protecting the salaries and livelihoods of its members. Thus, they fight efforts to cut physician pay tooth and nail. The second, though, is perhaps more insidious. The cost to go to med school is north of $200k, and heading towards $250K+ (my tuition and money to live on will total $70k). That's not even counting any debt you may have from undergrad. Thus, many can MDs graduate with nearly $400k of debt. As a resident, you still don't make that much (more than a post-doc in the biological sciences, but then they don't usually have loans from grad school). This pushes a lot of MDs towards specialties that have large financial rewards, and away from both primary care and basic research (both of which I think are necessary). Finally, regardless what physician pay is, Brew said, the biggest costs are all the administrative ones. I just had some tests, and the billing system at the hospital I went to involved them sending me and the insurance a bill, the insurance then reviewing the charges, and then the hospital billing me what was left over. Each step of that adds up. The only sane thing is to nationalize health care.

Posted by: Pat | May 20, 2005 5:51:18 PM

We've essentially weeded out anyone who doesn't like science from attending med school,

Here we go again. In my first life I was an engineer (never used multi-variable calculus there, either) and I respect numbers and data and it makes me nuts when you liberal arts majors start talking about this stuff.

There is a wide variation in doctors salaries mostly influenced by specialty. There are certainly doctors who make $1M per year. I have a friend whose sister makes that as a dermatologist with a strictly cosmetic practice. I suspect that more than a few plastic surgeons are also in that range. However, those of us who are not doing cosmetic work but are down in the trenches are making a fraction of that amount. I make somewhat more than I made as an engineer and about as much as my PhD husband. Since physician compensation makes up about 10% of our medical costs, slashing salaries in half would yield a big 5% cost savings. At that point (especially since W's taking away my SS), I'd be better off going back to engineering. One of my NP students recently told me that NPs make about 80% of their physician counterparts' salaries, so switching to larger component of NPs would reduce costs by 1-2% at best.

I work with NPs and I volunteer a lot of hours to teach NPs. I like NP/PAs and I think that they have a place in health care. However, substituting NPs for more highly trained physicians is not going to work in all situations. When I'm lying on that OR table waiting for a doc to crack my chest and sew grafts to my coronary arteries, I really, really want her to have had a lot of training.

Ezra is right about the pediatrician treating flu. Most of the people that I see every day should have just stayed home and called Mom for advice. On the other hand it does take a little bit more training to pick up the weird and potentially life threatening conditions that wander in every week or two.

There are several reasons why there is a shortage of nurses (and math teachers). The main reason is that there are other careers open to women now. My mother was one of two women in her graduating class with a science degree. Now women with an interest in science or math can become doctors and engineers rather than nurses and math teachers. You argue that nurses should be paid more in order to attract more people into the intellectually and physically demanding field and then turn around and argue that there wouldn't be a shortage of people attracted to the intellectually demanding field of medicine if they were paid less.

When I was in medical school and residency I never spent "30 hours on my feet". What you see on TV is exagerated. Frankly, some of my colleagues exagerate the horrors of residency. However, I've been to both grad school and medical school and in my case I certainly had to work a lot harder the second time around. I don't deny that you could knock a year or two off the training by eliminating all hard undergrad courses like history and English and maybe even eliminating some of those fun and easy calculus classes. I'm sure that there is a better way to sort out who's capable of mastering the enormous amount of material required in medical school, but at this point grades in science and math classes are the best they seem to have come up with.

Oh yeah, the AMA is largely irrelevant. A little more than a third of American MDs join. If the state of California wanted to produce more medical school graduates, the state would merely have to pony up the cash for the UC system and out would pop more MDs. Teaching medical students and residents is extremely labor intensive. Oral Roberts University tried to start a medical school but found that it was too expensive.

Posted by: J Bean | May 20, 2005 6:38:16 PM

"Oral Roberts University tried to start a medical school but found that it was too expensive."

Thank God. (pun intended)

Posted by: TJ | May 20, 2005 7:14:24 PM

J -- No one is saying NP's should be cracking open chests. That's the definition of why we need doctors. At the same time, the best doctor I've ever had in my life -- and one who, when treating my gf for something, recognized the condition as relating to a rare genetic disorder my gf has -- was an NP. There's no doubt in my mind that with good training, they can fill a powerful need in our medical system and do so at much lower cost.

Ezra, you're a smart kid, but all of you bloggers keep making the same, goofy argument here. I wish that I could write as well as you and your colleagues, but I are proud to be a inggenir, so let me rephrase it as an analogy:

Kevin/Ezra/Matt says that Paul Krugman makes a lot of money and universities are all facing a budget crunch, therefore that financial problem is due to excessively high salaries paid to professors. I read this and get all riled up and respond that most college professors don't make as much money as PK and besides professor compensation is only a small part of the universities' budgets. Then K/E/M advances the idea that college professor salaries would come down if we started hiring people with master's degrees to teach rather than doctorates. At which point I throw up my hands and snarl that people with doctorates deserve to make more money than people with masters level degree because they have a bigger investment in opportunity and direct costs as well as a broader level of knowledge that allows them to generally perform at a higher level.

Sure, there are NPs who perform as well at times as physicians and if you gave them more training and more responsibility, they would do even better. Except that they would then be doctors and would probably wind up getting paid 100% of a doctor's salary rather than 80%.

Anyway, what I'm arguing is that you guys keep making a specious argument. Physician compensation is a small part of healthcare costs and while there are various ways you could trim small amounts of money out of the national healthcare budget by taking it out of my paycheck, that's not going to get you to the goal that you want.

Interestingly, France is trying to trim its healthcare budget by training fewer physicians in order to restrict access by its famously doctor-shopping population.

Posted by: J Bean | May 20, 2005 8:49:21 PM

As an RN and an aspiring NP, I couldn't agree with you more. We also need more physician assistants and pharmacists. The other Western countries have been using master's prepared providers for decades, and they all get better health outcomes than we do.

Posted by: Rebecca Allen, PhD | May 21, 2005 3:11:38 AM

why not reform medical education and medical practice?

government funds the training of medical doctors

why not rationalize the process of deciding how many doctors to train, what to train them in and what to train them (and others to do)

is there some compelling reason to leave these matters in the hands of the ama?

have they demonstrated a concern for the common good?

Posted by: james | May 21, 2005 11:52:24 AM

I'm not sure the ten per cent estimate of the share of the nation's health bill is a correct number. I think it's closer to twenty but I'm getting bogged down in definitions trying to sort it out. A good start is:

http://www.cms.hhs.gov/statistics/nhe/historical/chart.asp

In any case, whether doctors receive a ten per cent or a twenty or even twenty five per cent share of the pie, its a significant chunk. If the same work can be done for half the price, we are talking about savings of seventy-five to 150 billion dollars annually.

Even if the overpay of physicians is only one or two per cent of the nation's bill, why not fix it?

Posted by: QuietStorm | May 21, 2005 2:40:09 PM

How do you determine "overpay"? What's too much? Why not cut salaries for people in the insurance field instead? Physicians in the US make 3 times what French physicians and RNs out earn their French counterparts 4 to 1. American NP/PAs out earn French master's level physicians so are they overpaid? On the other hand American MDs make somewhat less than American lawyers and American B-school grads. Are all American professionals overpaid? My husband has a PhD in a science field and has about as many years of education as I do. He works in industry and we both earn about the same amount. Is he overpaid too or is it just me? How do you determine comparative worth? When you start dictating salaries don't we start calling that economic system something else that starts with a "c"?

Posted by: J Bean | May 21, 2005 4:58:37 PM

If you assume a 40 hour work week, I make almost $90/hour. That's a very good income. However, I work a lot more hours than that. The average MD works 53 hours/week. If you assume that I work that many hours (I actually work more), then I make about $65/hour. Now, the last time I hired a plumber, about 3 years ago, I paid him ... $65/hour. If plumbers earned less, then housing would be cheaper. Are plumbers overpaid too or is it just us physicians?

Posted by: J Bean | May 21, 2005 5:17:59 PM

QS: That 22% for clinical services would include my overhead: office nurses, case managers, receptionists, utilities, office rent, supplies, etc. I suspect that we're lucky if we net 50% of our gross income as physician salary. The numbers that I have seen for salary are 10-12%, but from the source that you have provided, it looks like my figure of 10-12% is a bit high.

Posted by: J Bean | May 21, 2005 5:35:21 PM

Jbean: I think you missed the word "if" in my statement. I said that IF the overpay is one or two per cent of the nation's tab, we should fix it. I don't know how much the overpay is.

You seem to be suggesting, with your reference to the "c" word, that our current system is a free market one when that is anything but the case. Firstly, Medicare and other agencies pay over half the tab and do so at whatever rates they choose. The privates tend to track Medicare rates in terms of trend although their absolute levels are higher in order to cover their enormous bureaucracies.

And then there is the nature of the health consumer who usually "chooses" to spend whatever his doctor (the provider) tells her to. If a doctor tells you to come back in 6 weeks or to have this or that test done, most people do it and don't ask questions. McDonalds can't order you to come back for another Big Mac tomorrow and Toyota can't make you buy more cars either. This supplier-induced demand, as the economists call it, is a huge problem. There was a story somewhere in Michigan last year which captures this well. A hospital chain announced plans to build a new facility in a town that already had an existing hospital. Major corporations and insurers banded together to attempt to prohibit the facility from being built. They argued that, in health care, supply creates its own demand and the new facility was likely to add to costs at no benefit to the community. This is far afield from physician salary but it makes the point that health care is not operating under free market economics.

Lastly, what excesses exist in physician compensation are not likely to be evenly distributed. There are some specialties that make four or five times, on average, what others do without any obvious reason why.

Posted by: QuietStorm | May 21, 2005 7:14:32 PM

I'm an RN, and from what I've seen, J Bean's comments are right on... except that there definitely are a lot of residents working insane hours with insane workloads and it has a really unfortunate effect on quality of care. Basically the floor nurses end up compensating for the parts of the doctor's brain that have been fried, and doing all the communication with the patient that the doctor doesn't have time to do. (This is much more the case for surgeons; were you a medicine resident, J?)

And as Electoral Math says, RN salaries are pretty good. In my experience, the nursing shortage these days is almost entirely due to the crappy working conditions at most hospitals: you're often expected to do the work of two or three people (not including the brain-fried resident) in an environment where most patients are quite a bit sicker than they would've been 20 years ago (since otherwise they get sent home promptly) and where there is an increasing mountain of paperwork, and you're expected to be the one who's always nice and smiley. Hospitals have been financially squeezed by HMOs and mergers, and are reluctant to hire more than the bare minimum of nursing staff, and under these conditions it's hard to retain the staff you do hire. (I know not all nursing jobs are on hospital floors, but that's the entry-level job you do out of school and it's where you get most of your training.) Everyone I know who's been in the field more than 20 years agrees that all of the above has gotten significantly worse in that time, though pay has gotten better.

And as J Bean pointed out, women these days have more options and that's a good thing. I don't think that's "the main reason" for the shortage, though. There are still plenty of people going into nursing school with a real interest in the field (including an increasing number of men)... but the attrition rate is very high once they see what it's like to work in the current American health care system.

From a lay point of view, another cost that hasn't been addressed is medication. It's been my ezperience that too many patients are overmedicated. I've learned that the simple solution is often a good preventive measure. Most of us know about lifestyle choices that are best for good health and most of us ignore them while we're young. It's later when life has caught up with us that we go to a doctor and say fix me. Insurance doesn't pay for most preventive measures so expensive tests and procedures are set up so that we don't pay out of pocket.

I have spent a lot of time learning about alternative measures to keep healthy and am willing to see an NP for evaluation. Major injuries require more advanced care. Herbs and meditation won't reset a broken limb. But finding disease where it isn't or making disorder instead of addressing the root causes isn't helpful. I see more of this since the drug companies have started advertising in print and on TV.

Perhaps I rant about this because I found that I tend to overreact to pharmaceuticals and most doctors haven't seen fit to acknowledge this. It was an NP who agreed that I needed to find alternatives. It was a naturopath who helped me find them.

There needs to be a place in our health care system for a range of qualified alternative practitioners some of whom are noticably less expensive for those of us who are in rural areas with limited choices and on limited incomes with no insurance.

There's no question that MD's deserve their income. I'm less sure that insurance should be a for-profit industry. I'm from the mutual agency time period. Nurses carry a heavy load and their compensation should reflect that. Pharmacists play an essential role in tracking meds for their clients, sometimes catching serious errors. All these professionals are a part of the team. Hospitals are necessary for several reasons. Clinics can often deal with conditions to keep them from becoming life-threatening. It seems to me we have the makings of a good system but it doesn't work. Perhaps the single payer system could be a part of the answer.

I'm a Californian transplanted to DC, and surprisingly at peace with it. Or at least I was till it started getting colder. Job-wise, I'm the staff writer for The American Prospect. In the past, I've written for the Washington Monthly, the LA Weekly, The LA Times, The New Republic, Slate, The New York Sun, and the Gadflyer. I'm a damn good cook. No, really. Want to know more? E-mail, I'm friendly.